Select Committee on Health Written Evidence

Memorandum by Dr Liam O'Hara (PS 47)

  With respect to your call for opinions on your inquiry into Patient safety, I wish to submit some views from the perspective of a medical practitioner in primary care with a Healthcare law degree.

  1.  To begin with I think one ought to restate elements of the Hippocratic Oath, which provide insights into medical philosophy.

    "|I will prescribe regimen for the good of my patients according to my ability and my judgement and never do harm to anyone. To please no one will I prescribe a deadly drug, nor give advice which may cause his death|"

    "|If I keep this oath faithfully, may I enjoy my life and practise my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot."

  Allied to these touchstones one must add the pillars of aspiration and professionalism to understand the positive virtues of "the medical personality". How these virtues are nurtured in the case of the NHS by utilitarian and political envelopes seems to be the nub of your inquiry.

  2.  Patient safety is core to medical practice in the sense of "duty of care", it can become diluted and disfigured when utilitarian agendas manifest. The hand holding the smoking gun describes the individual element of the error, and is an easy target to attach blame, and whichever flavour of accountability to circumscribe the individual's contribution. Systemic accountabilities have traditionally been very difficult to ascribe a legal personality to and hitherto, especially in the case of the NHS, have slid away from any judicial examination. It is a common given that the greater bulk of responsibility for clinical negligence ie derogated patient safety, is to be found in system failures.

  3.  Clinical practice is not a science but an art, it employs science to direct and instruct the art, within the therapeutic relationship. Indeed clinical practitioners are a sump to absorb and manage the risk brought forth in the therapeutic encounter. Directed initially by non-malificence they already utilize the precautionary principle, prior to any beneficent act they may be able to offer. Thus far practitioners have been judged in the civil setting according to a justifiable and reasonable standard. This reasonable ingredient within a standard of adjudication allows for manipulation; it is not an aspirational standard. Plainly avoidable risk has to be defined to a standard, one described to the expert standard of conduct rather than the reasonable standard, fulfils the aspirational quest, and extinguishes manipulation of the reasonable standard.

  4.  I do not think there is any public perception of the interplay between risk and health policy, political manipulation has packaged healthcare into a commodity containing a warranty. This mixture of a service product containing risk defines our current attitude to patient safety. Can clinical practice ever be risk-free? Plainly the answer is no, can risk be understood and contained or reduced? I think the answer to this is yes.

  5.  How then to understand clinical risk and its management? Secondary care contains clinical risk managers, who educate clinical staff as to risk and examine complaints. In primary care a far looser risk management/analysis exists, beit at a micro (practice level), local (geographic level) or Primary Care Trust (PCT) level. Beyond these levels we have NPSA, NHSLA, Healthcare Commission, Ombudsman and perhaps even the Coroner. Indeed a formidable tapestry. The key to risk and its understanding is communication. To what degree, if at all, do the threads listed, communicate between each other, and if so, what and to whom do they educate? Experience is that the National Health Service titleage is a misnomer, pit face experience directs a different eponym FHS, namely Fragmented Health Service. In the instant inquiry pertaining to patient safety it is the experience of practicing clinicians which is paramount as to their perception how risk is managed at a personal, practice, departmental level and how the agencies listed above interact with pit face personnel. Education is a two way process, 24/7 and the FHS could learn from creative external bodies such as Toyota with its Zen constructs of genchi genbutsu - go and see for yourself, kaizen—continuous improvement, jikote kanketsu - quality through ownership, jishoken - fresh eyes approach, and yokoten - sharing and cascading lessons learnt. This example provides the tools for innovative assimilation of risk events. To see a system currently working and adopting the ingredients of this committee's inquiry one has to look at the Scandinavian No-Blame compensation system as exemplified by "Patientfðöñrsðäñkringsfðöñreningen", this system has been working since the early 1970's. Originating initially in Sweden, over the last five years, all its Nordic neighbours have now embraced the system.

  6.  The terms of reference in this inquiry use terms such as "adequate measurement", "policy", "appropriateness of the objectives", "national policy", "cost effective", and "national targets". This slavish pursuit of objective measurement, the easily measured, neglecting the more important virtue of what is not measurable is usually more important (Gresham's law). Indeed ".. what gets measured gets managed—even when it's pointless to measure and manage it, and even if it harms the purpose of the organisation to do so..." The purpose of any exercise involving managing human conduct/behaviour needs sage counsel lest it fall into the law of dysfunctional consequences. Mintzberg a management educator proposed that starting ".. from the premise that we can't measure what matters gives managers the best chance of realistically facing up to their challenge". It is too easy to fall into the example of "|Corporate managers start off trying to manage what they want, and finish up wanting what they can measure|" Plainly measurements if valid and valuable need to be formulated in knowledge of the above observations.

  7.  From the perspective of current effectiveness of NPSA, NHSLA, and the Healthcare commission upon clinician's behaviour at the pit face, I think the majority of practitioners are aware of the alphabetical contribution to the titles, but little more. This says it all; one cannot communicate across a vacuum. Communication and dialogue are everything.

  8.  Targets and the naive simplicity they derive from are delusional; Ackoff has distilled it as ".. the only problems that have simple solutions are simple problems. The only managers with simple problems are those with simple minds. Problems that arise in organisations are almost always the product of interactions of parts, never the action of a simple part". Focussing on top down mantra and targeting the individual parts in a shame/blame guise makes things at a system-wide level function worse. If enough pressure is applied people will meet targets, and in doing so destroy the organisation. So called junk management without any sentience of genchi getsubu leads to discontent, demoralisation and dysfunctional behaviours. The absence of any method and the deification of the target lead to disengagement.

  9.  What is needed is acknowledgement of something akin to genchi getsubu and a system that cultivates and co-ordinates risk analysis in an aspirational environment with none of the traditional shame/blame destructive schemas. Such a model exists within the Toyota Production System, as alluded to earlier. The cards already exist in the poker game that is healthcare; the problem is, the hand that is playing them. The agents and organisations need a truly independent compass, allied to this they need to be trusted without any application of political shackles. As is plain in the human condition handbags and super-egos can disrupt the best laid plans; collegiate and statutory bodies are not immune from such agents.

  10.  Patient safety is a 24/7 construct with hot spots appearing at certain times of the day, days of the week and seasons of the year. It is something that needs cognisance of its cycles and the human and systematic contributions. What is needed is a more sage use of the boards and agents that already exist; an independent Board of safety separate from all other boards would be a start. This body would be allowed to shape the garnering of pit face experience and facilitate its experience to feed into the executive and be allowed to direct policy with patient safety as its remit. This plainly will feel alien to management if not apocalyptic. However this is their problem and indeed I would say the current situation is of their creation beit through higher coercion. The solution involves innovative, creative let us say it, "World Class thinking". In a public service aping "World Class provision", patient safety is plainly a tandem passenger on this journey.

  11.  World Class direction of clinical care and patient safety involves putting the professionals back in the driving seat without any utilitarian obfuscation as to dilute the recipe. The ingredients of any Board of safety would be risk managers, clinicians, hospital legal representatives, operational directors, and an executive champion. It would have a 24/7 presence, with active communication and dialogue with all healthcare delivery personnel. The chair of the board needs to be a rather special chef, someone who is an experienced clinician and one mindful of Root cause analysis, accountability, legal issues, transparency, allied external bodies above all approachable, a sense of humour and with no axes, apart from patient safety, to grind. A tall order for an alchemist! I have recently seen a novel structure made manifest, the NHS Institute is making attempts to cultivate medical leadership at undergraduate and junior level, which could be harmonized into risk management educational role.

  12.  Primary care, how does risk management sit in this field? I would say in a piece-meal manner. The same TPS system approach I have described for secondary care could be levied at primary care with all its agents. The co-ordination of the information received is perhaps the most difficult, and could be the most beneficial. I would suggest the Coroner service be given a pivotal role in the assimilation and co-ordination of patient safety issues by all primary care staff, they feeding information to the coroner by a card service similar to the Yellow card system used for suspected adverse drug reactions. The Coroner being independent from PCT's and any political manipulation would facilitate an aspirational democracy for patient safety in the largest pool of NHS to patient contact (90% of patient contact with the NHS is through primary care). The Coroner being a medical and legally minded agent has the necessary remit and skills to hold this candle. This pivotal agent could then utilize the knowledge gained in dialogue with the board of safety in secondary care to inspire a virtuous cycle of continuing improvement in patient safety, an important side effect of this being improved healthcare provision. Dialogue between the Ombudsman, or an amalgamation of this role into a locality driven patient safety division, driven by lessons learnt from complaints (Kaizen) would provide a new way of using complaints and clinical experiences to improve the patient experience and amplify patient safety in Healthcare delivery.

  13.  In my estimation "cost-effective" is an anathema to patient safety, and ought to be removed from usage in this instance.

  14.  The implementation of learning from clinical risk pulls the discourse towards the composition of using the utility garnered to deter future occurrences; allegedly one of the basic elements of Tort law, but one rarely seen in the quest for Quantum. The Quantum of education is one impossible to numerate, but is plainly far more valuable. Members of the Medical indemnifier organisations receive missives about cock-ups, and the respective practitioner contributions within, allied to advice upon how to avoid repeat; so too ought the NHS. Education and dialogue stimulate confidence in systems and people; this creates positivism inspiring the individual and the system to aspire to yet higher achievement. Education can be oral or written, I see education as being a fundamental vista upon the employer, indeed a duty. The spectacular failure of the NHS University demonstrates the fact it is not the body but rather people that make things happen. Local education like cellular networks provide the best coverage of populations, the value placed upon the agents of education shows how much the system values the message. Such agents need the capacity and personality to engage the topic, one that is not easy but is core to all healthcare providers. Indeed an old observation is that ".. risk is everyone's business..", none more so than in the context of Healthcare. Imaginative solutions need to be harvested and grasped lest this slip from the conscious mind.

  15.  Summarising I feel Healthcare is a game of cards, whichever game you want to play it is the manner in which the respective cards are played as to the rules of the game. Axiomatic to the delivery of Healthcare is the analysis of risk, something that practitioners do on a daily basis. Trying to elevate the functioning of healthcare delivery plainly feeds into practitioner philosophy and morale. Utilizing subtle psychological schemas to feed into the practitioner psyche requires innovative ideas which policy makers need to be aware of. Central to all human endeavour is trust, without this fundamental ingredient all fails. Avoidability is a given necessity in my view to address patient safety and the practitioner component borne within, addressing this sagely ought to reinvigorate professionalism. Utilizing aspects of the Toyota Production System and looking towards a Scandinavian No Blame model of compensation would provide a start to advancing this agenda. Profitable shuffling of the current agents within the game such as the Coroners office, Board of Safety and emulating the Yellow card schemes would strengthen the tapestry of patient safety. Above all education of all healthcare providers on a continual non-threatening basis is the route to strive for, placing the therapeutic relationship at the heart of any lessons to be learnt, apologies to be made and wisdom to be imparted. Any healthcare system revolves around people, by this I mean the patient and practitioner. Central to it will always be the style and manner of the therapeutic relationship. Employing the abstract of avoidability to an expert standard is something all practitioners at an individual level strive for, and is something we ought systematically nurture and protect. The manner of its cultivation and shepherding is something that needs great care, caution and sensitivity. Its success would be central to a "World Class" Health Service.


  I am indebted to Simon Calder and his management column in the business section from "The Observer" for his alternative view point on "management".

  I have found the tome "Errors, Medicine and the Law" by Alexander McCall-Smith and Alan Merrey a valuable seam of wise observations.

  I am indebted to all on "Doctor Net UK" for their eclectic mixture of wit, observation, experience and reality that helps to give this website its sage personality, and informs all who visit it.

  "Clinical Risk Management" by Charles Vincent et al.

  "Structural change in healthcare: what's the attraction?" Coid & Davies, JRSM Vol 1001, No 6, p 2788-281.

Dr L.M. O'Hara, MB ChB LLM

September 2008

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